Q&A with Dr. Mark Sullivan

According to the CDC, the number of opioids prescribed in the U.S. has quadrupled in the past 15 years, even though there's been no change in the amount of pain American patients report. In 2013, health care providers wrote enough opioid prescriptions for every adult American to have their own bottle of pills. We talked to The University of Washington's Dr. Mark Sullivan about opioids, chronic pain, and the safest ways to treat patients.

What sorts of situations would result in a patient being prescribed an opioid?

Opioids are frequently prescribed to treat both acute pain and chronic pain.

Acute pain results from a one-off injury. Typically, something that would bring a patient to the emergency room: a broken femur, an intense injury. This type of pain is short-term.

Chronic pain is defined as non-cancer pain that lasts longer than six months. Fibromyalgia, back problems, migraines—these are examples of chronic pain.

What considerations should doctors make before writing a patient a prescription for an opioid?

First and foremost, we need to distinguish acute pain from chronic pain. Opioids can be a part of acute pain treatment, and in these cases, doctors should follow the CDC guideline for prescribing opioids. Prescriptions shouldn’t be written for longer than 3–7 days. Any use of opioids for more than a week needs a good follow-up assessment. Prescribe a lower number of pills, without refills, so that the patient has to come back in and see you before getting more. And finally, avoid long-acting opioids like OxyContin; these formulations are far more dangerous than short-acting opioids like oxycodone.

Any patient who receives an opioid prescription shouldn’t leave without a plan to get off these pills eventually. The bottom line is, there’s no way to know which patients will be high-risk. People really don’t need more than 3–7 days' worth of these pills at a time. There’s good evidence that pills that are left over often end up in the wrong hands. It’s always safer to write a low-dose prescription with fewer or no refills, and then work with your patient from there.

Are there effective ways to manage pain without opioids?

Absolutely. None of them provide the quick-fix, instant relief that an opioid provides (at first), but in the long term, they are safer and more effective.

Tai Chi, acupuncture, mindfulness meditation. Anti-depressants, anti-convulsants. Very few of those make you feel better on the same day you start them; they require time, patience, and commitment.

Why do doctors prescribe opioids for chronic pain if they’re so dangerous?

One of the biggest reasons we’re seeing such serious opioid overprescribing right now is that physicians can feel pressure to provide immediate relief for patients.

None of the alternative therapies I mentioned before work instantly. But an opioid often does. So there’s no better way to make your patient feel better on the ride home from the office than to hand out an opioid prescription. It promises immediate short-term relief, but sets the patient up for more problems down the road: dependence, decreased efficacy, higher doses, addiction, potential overdose. Not to mention everyday opioid side effects like constipation, nausea, and sleepiness.

Do Prescription Drug Monitoring Programs prevent people who suffer from chronic pain from receiving medication?

That’s not what they’re designed to do. They’re designed to detect and deter multiple prescribers when the doctors don’t know each other. A PDMP certainly doesn’t prevent a single practitioner from prescribing what they need to prescribe.

If you oppose PDMPs, you have to believe that patients know better than doctors. As a doctor, I don’t believe that’s the case.

What advice would you give to doctors who prescribe opioids for chronic pain?

The simple answer is: Don’t. The longer answer is: Low-dose intermittent opioids may provide benefit for some low-risk patients.

We’ve tried out the idea that opioids are a broadly effective and safe strategy for chronic pain. The medical community now believes that that’s not true. We now believe that opioids are a beneficial long-term treatment for chronic pain in a small minority of patients.

Opioids shouldn’t be the first choice for chronic pain. There’s just no solid evidence that they work.

Dr. Mark Sullivan received his M.D. and his Ph.D. in Philosophy from Vanderbilt University. After completing an internship in Family Medicine at University of Missouri, he completed a residency in Psychiatry at the University of Washington in 1988. He is now Professor of Psychiatry and Behavioral Sciences as well as Adjunct Professor of Anesthesiology and Pain Medicine and Adjunct Professor of Bioethics and Humanities at the University of Washington. He has served as attending physician in the UW Center for Pain Relief for over 25 years, where he is Co-Director of Behavioral Health Services. He has published over 250 peer-reviewed articles, many on chronic pain. He has new a book from Oxford University Press titled, The Patient as Agent of Health and Health Care.

Originally published in 2018.